Sex, pain, and Endometriosis

Sex, pain, and Endometriosis

These are common statements that I hear within my clinic as a Pelvic Health Physiotherapist, especially among those with Endometriosis. Painful penetrative sex (or Dyspareunia) is not a diagnosis in itself and can be due to many reasons. 

One of the reasons why this may be the case for Endo sufferers is that the most common place for Endo to reside is within the rectovaginal space or The Pouch of Douglas (only a woman’s anatomy could be named after a guy but that is another rant for another time). Particularly with deep penetration, this can then press on these areas to create pain and often causes certain positions to be “off the table” for couples. 

There can also be sensitization around the vulva area, including the urethra (where you pee from), vaginal opening, and perineum (the tissue in between your vagina and anus), and may be referred to as Vulvodynia. This is due to a conditioned response to persistent pain and as the body anticipates a painful response, it tries to protect itself by making these areas of the body sensitised and thus painful. The consequence of this response can be tense pelvic floor muscles and this then makes penetration much harder to achieve comfortably.

Those who suffer from Endo can get stuck in a familiar negative cycle. Due to their last (or potentially every) experience with penetrative sex have been painful, their body then anticipates this response causing tension into the pelvic space and muscles. This will then reduce any form of natural lubrication, as the brain is too busy preparing itself for pain and hence arousal simply doesn’t happen. 

You now have ‘the perfect storm’ with the anticipation of pain, lack of lubrication, and a tense pelvic floor and so even if penetrative sex is achieved, it reinforces the body’s reaction as ‘correct’ and so will simply recreate this again and again and again. All in all, incredibly frustrating and potentially further traumatizing for Endo sufferers.  

Now I think it is important at this stage to clarify that I am referring to painful sex with penetration. This is NOT the definition of sex. Penis in Vagina (PIV) sex is simply ONE way of being intimate with someone and consequently, it is not necessary to pursue this if it does not interest you. However, I can fully understand the want to pursue more comfortable PIV sex for the benefit of relationships and potentially if they are looking to start a family.

So here are some tips that may help you achieve more comfortable PIV sex: 

Pillows & Positions

By using a pillow under the hips can help to reduce pressure on the rectovaginal space by opening the pelvis more. You can also use pillows under your knees if you find it hard to let your legs drop to the sides. The key is really your comfort, so use as many as you need.

Regarding positions, it can often be trial and error with your partner. Don’t be afraid to try different positions and communicate what feels better for you. Sometimes side lying or with one knee up and one knee down will feel better or being on top in order to control the depth of penetration. 

Pelvic Stretches & Mobility

It is common for those suffering with Endo to have quite tense and tender pelvic floors. By simply making time x3-4 week to perform some regular hip and pelvic stretches, this can help to relax the pelvis and other muscles in the area quite significantly.

One of my favourite exercises I ask clients to do regularly is a supported child’s pose position and what I refer to as ‘Balloon Breathing’. In this position, simply imagine a circle or balloon in your mind’s eye and as you inhale imagine this balloon or circle is increasing in size and filling the space between your chest and your pelvis right down to your back passage. Hold this feeling of expansion for a moment and then slowly exhale and imagine that balloon or circle is getting smaller again. This can be a great way of calming the nervous system and also relax the pelvic floor. 

Choosing the right time for PIV sex

Understanding your cycle is really key with Endo and so if you know that your worse times for pain are ovulation and bleed times, then perhaps avoid penetrative sex during these times. You may feel comfortable being intimate with your partner and just staying ‘outside of the box’. 

Gadgets & Gizmos that can help

There has been a massive revolution of sexual aids that now focus on women’s pleasure as much as mens. Hooray!!

There has also been big advances with regards to sexual aids/tools that may help to reduce painful PIV sex. One of these is called an Ohnut which is formed from medical grade silicone and is slipped over the penis or toy to act as a buffer to reduce the depth of penetration. These rings can then be removed one at a time as penetration becomes more comfortable.

Dilators/Vibrators can also be helpful to help bridge the gap between not being able to have any form of penetration and resuming it. These can come in all different shapes and sizes (depending on what you are able to achieve to start with) and can be used independently or with partners to help reduce the threat of penetration being uncomfortable.

If you are working with a Pelvic Health Physiotherapist, they may also suggest that you use a Therapeutic Wand at home to help alleviate tension within the pelvic floor and this can help keep the pelvic floor more relaxed. And last but by no means least, is Lubricant. This can be a game changer for some couples and getting the RIGHT lubricant for you is key. I would always recommend an organic lubricant that is less likely to affect your vaginal pH and avoid the nasties in processed lubricants. A great example would be BONK or YES brand, which both come in water or oil based depending on what you are using it with. 

Bank some positive sexual experiences

This is essential in being able to overcome previously painful penetrative sex.

By continuing to have sex that is painful, this will only reinforce your body’s need to protect itself. It can be likened to you holding your hand on a hot stove whilst your body is screaming at you to take it off. By trying to either disconnect or ignore that pain, this will only make your response more likely to persist.

I would suggest for those who are struggling with this issue and have never mentioned it to their partner, to please speak up. You can then make a plan together as to how ‘sex’ may look for you for right now and that may mean that penetration is ‘off the table’ until you can deposit enough positive sexual experiences in the bank. This means sexual intimacy was pleasurable for you and not painful in any way. By experiencing more pleasure than pain,  your body is more likely to look forward to sexual intimacy and not feel threatened by it and hence you will be more aroused and libido will increase.

If you are struggling to communicate with your partner regarding this issue, then liaising with a Sexual Therapist or Psychologist can be of help as well as a Pelvic Health Physiotherapist.  


If you are keen to learn more about this topic then these are some great accounts to follow on social media platforms: 

@thesexdoctor: Karen Gurney (UK)

@sextherapistjo: Jo Robertson (NZ)

@vaginismuswho: Rosie (UK)

@intimaterose: Dr Amanda Olsen (USA)